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Analgesia for forceps delivery

Article  in  Cochrane database of systematic reviews · September 2013

DOI: 10.1002/14651858.CD008878.pub2 · Source: PubMed

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Payam Nikpoor Emily Shepherd

Monash Health-Dandenong Hospital University of Adelaide
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 566 FEB. 24, 1962 CORRESPONDENCE
work I have often seen authors misquoted, but never
to such a degree as this. My exact words (November 25,
p. 1434) were, " The virtues of A.T.S. have never been
-adequately proved and there is still doubt whether it
influences the course of tetanus once clinical symptoms
have begun." This has a totally different meaning from
what these good doctors said I said.
Dr. Keith J. Randall (December 16, p. 1647) is
horrified by my letter advocating that A.T.S. should
be banned from casualty departments and replaced by
tetanus toxoid. I am happy to say that he quotes me
correctly and I hope that his horror will be mitigated
when he reads Dr. M. W. Tisdall's letter which follows
his own in the same journal. In this Dr. Tisdall describes
the case of a 10-year-old boy who died of tetanus despite
a prophylactic dose of 1,500 units of A.T.S. given by
his G.P. I can quote two similar cases in my own
experience and recently had a child who developed
tetanus without any history of trauma and without a
single lesion detectable over her whole body, which was
carefully examined with a magnifying lens-an indica-
tion of the variability of the disease.
I agree with both these letters that by the use of
prophylactic A.T.S. the incidence of tetanus was
gradually reduced during the American Independence
Day celebrations between 1903 and 1914-from 100:
1,000 to 0: 1,000 and that during the first world war
the incidence of tetanus was also greatly reduced by the
use of A.T.S. But do these figures apply to normal
civilian life in London, Birmingham, or even Orpington
in 1962 where horse-drawn traffic with its consequent
contamination of the streets has virtually disappeared ?
We have lulled ourselves so completely by the liberal
use of A.T.S. that no one in recent years has ever
attempted to find the answer. The time is due for such
a clinical trial. I would suggest that some courageous
casualty officer divides his casualty cases into three
groups. One group would receive 1,500 units A.T.S.,
one tetanus toxoid (Tet/Vac. B.P.) 1 ml. to be repeated
in four weeks, and the third group, if he is really
courageous, would receive only an antibiotic. By
sequential analysis we should be able to get an answer
with minimal damage to the patient and which would
end this controversy once and for all.
Everyone seems agreed that universal immunization
of babies with Tet/Vac. with subsequent booster doses
would virtually eliminate tetanus and also the need for
tattoos or disks as some of your readers suggest. Surely
it is time that the whole matter be taken up at Govern-
ment level ? If South Africa can eliminate poliomyelitis
by universal oral immunization there is no reason why
Britain should not take a lead in eliminating tetanus.
If by advocating a ban-the-A.T.S. bomb I have aroused
sufficient feelings on the matter, then my purpose will
have been well and truly served.-I am, etc.,
KSerksdorp,
South Africa. PNu CATZEL.
PINCUS AZL
SIR,-The correspondence on this subject has not
stressed the fact that all members of the armed Forces,
in the past twenty years at least, will have been actively
immunized against tetanus. I have had to treat two or
three severe delayed reactions to A.T.S. in such men,
and I have seen countless others who have been given
A.T.S. in casualty departments when a booster dose of
toxoid would have been much better and much safer
prophylaxis.-I am, etc.,
Exeter. M. E. M. COOK.
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BiuRITI
MEDICAL JOURNAL
Analgesia for Forceps Delivery
SIR,-Mr. J. F. O'Sullivan's paper (January 20, 'p. 151)
focuses attention on the advantages of local anaesthesia
in obstetric practice and describes a most useful adjuvant
to infiltration with lignocaine. Promethazine, however,
is not without its dangers in that it lowers the systolic
blood-pressure by as much as 30 mm. Hg. Should a
post-partum haemorrhage follow there may be estab-
lished a severe state of shock which, in a patient's home,
may become irreversible.
Although no third stage abnormalities have been
reported I feel that when phenothiazine derivatives are
used intravenous ergometrine 0.5 mg. (or intramuscular
ergometrine 0.5 mg. with hyaluronidase) should be
administered when the head is crowned.
Gentle technique in infiltrating the perineum using
the method advocated by Professor G. G. Lennon at
the Annual Meeting in 1960 (July 2, 1960, p. 55) should
make intravenous therapy unnecessary in all but the
most restless of patients.-I am, etc.,
Liverpool 18 MERVYN GOODMAN.
Christmas Disease and Capillary Abnormality
SIR,-The article by Dr. E. K. Blackburn and others
on Christmas disease associated with primary capillary
abnormalities (January 20, p. 154) prompts us to record
a similar case which we have recently investigated. The
patient is a boy of 8 years with a long history of
haemorrhagic episodes for which he has been admitted
to hospital on at least eleven occasions. Epistaxes have
occurred frequently since the age of 1 month, and the
finding of a constantly prolonged bleeding-time led to
the diagnosis of von Willebrand's disease during infancy.
Eruption of the milk teeth regularly caused excessive
blood loss, and he has always suffered both from spon-
taneous bruising and from prolonged bleeding from
superficial cuts. He has also had haemarthroses on two
occasions and crops of purpura from time to time.
The results of our investigations are shown in the
Table. As the boy is a foster-child, it has unfortunately
been impossible to carry out family studies, but it is
Results of Laboratory Tests
Patient Normal Range
Bletding-time (Ivy) . . >20 min. Up to 7 min.
Clotting-time (Lee and White)
Prothrombin time (Quick)
I I min.
1 5 sec.
5-10 min.
12 sec.
consumption index 44% Up to O°'
Thromboplastin generation test Serum abnormal
Plasma normal
AntihMemophilic globulin
Christmas factor
120-140%
16%
Platelets. 140,000!c.mm.
Platelet morphology .. Normal
9 thromboplastic function Normal
known that neither his mother, her parents, nor any of
her three siblings have ever suffered from excessive
bleeding.
Nilsson, Blomback, and Blombick' have demon-
strated that both the bleeding-time and plasma anti-
haemophilic globulin concentration of patients with
von Willebrand's disease can be corrected by the
administration of a fraction of normal or haemophilic
plasma, and this has subsequently been confirmed by
Cornu et al.2 and others. It would be of interest to
know whether any of the abnormalities demonstrated in
their patients by Dr. Blackburn and his collaborators